- Date
- 4/17/2026
- Report number
- 00470989-AP-423333
- Type
- Abuse: Neglect
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to properly plan care
- Result
- Substantiated
- Findings
- On or about April 17, 2026, the Alleged Victim (AV) experienced an unwitnessed fall after attempting to transfer without assistance. Based on facility documentation and interviews, AV activated his/her pendant alarm at approximately 3:25 PM and was found on the floor with a head injury and a forearm skin tear. AV is a known fall risk with a history of forgetting to use their call pendant, had multiple prior falls, including a head injury on February 26, 2026. Additional falls occurred after the April 17, 2026, incident with one fall on April 18, 2026, and another fall on April 19, 2026, with the April 19 incident involving another head injury. Despite repeated falls and documented risks, the facility did not implement additional or enhanced fall-prevention measures to mitigate AV's fall risk. The lack of adequate oversight and care planning resulted in continued falls and unreasonable discomfort to AV, constituting abuse by neglect as defined in OAR 411-020-0002(1)(b)(A)(i).
- Sanction
- RCFCP26-00681 $500.00 fine assessed